Dates: 07/09/ /09/2016, 11/10/16, 07/11/16 09/11/16 & 28/02/17 Medical Practitioner s name: Dr Thofim KAZI

Transcription

1 PUBLIC RECORD Dates: 07/09/ /09/2016, 11/10/16, 07/11/16 09/11/16 & 28/02/17 Medical Practitioner s name: Dr Thofim KAZI GMC reference number: Primary medical qualification: Type of case New - Misconduct MB BS 1993 University of London Outcome on impairment Not Impaired Summary of outcome No warning Tribunal: Lay Tribunal Member (Chair) Lay Tribunal Member: Medical Tribunal Member: Mr Andrew Lewis Mrs Susan Staveley Dr Leigh-Anne Hill Legal Assessor: Mr Alex Jacobs Tribunal Clerk: Ms Victoria Bean 07/09/ /09/2016, 11/10/16, & 07/11/16-09/11/16 Miss Rosanna Sheerin - 28/02/17 Attendance and Representation: Medical Practitioner: Medical Practitioner s Representative: GMC Representative: Present and represented except for 09/11/16 Ms Carol Davis, Counsel, instructed by BLM Law Ms Kathryn Johnson, Counsel 07/09/16 20/09/16, 09/11/16 & 28/02/17 Mr Jeremy Lasker, Counsel 08/11/16 1

2 Allegation and Findings of Fact That being registered under the Medical Act 1983 (as amended): 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: a. take an adequate medical history in that you did not enquire as to: i. any exacerbating and/or relieving factors; Found proved ii. the duration and periodicity of Patient A s symptoms; Found proved iii. any associated wheeze or sputum; Found proved iv. the suddenness of onset of Patient A s symptoms; Withdrawn by the GMC v. iv. any relevant lifestyle factors including: 1. caffeine intake; Found proved, as amended 2. smoking; Withdrawn by the GMC 3. alcohol intake; Withdrawn by the GMC 4. stress; Withdrawn by the GMC vi. v. any relevant family history; Found proved, as amended b. record that you had provide advice to advised Patient A to attend at an accident and emergency department in the event that her symptoms deteriorated; Found proved, as amended c. carry out an adequate examination in that you did not: i. measure the respiratory rate; Withdrawn by the GMC ii. measure the venous pressure; Withdrawn by the GMC iii. i. listen to the complete heart; Found proved, as amended iv. ii. listen to the and lungs; Found not proved, as amended 2

3 iv. carry out a peak flow exercise reading; Withdrawn by the GMC v. assess the level of oxygenation; Withdrawn by the GMC vi. iii. observe the calves for evidence of deep vein thrombosis; Found not proved, as amended d. exclude a diagnosis of: i. heart failure; Found not proved ii. iii. Pneumothorax; Found not proved Pulmonary embolism; Found not proved e. maintain an adequate record of the consultation in that you did not record the information as outlined at paragraph 1(a), c and to (d). Admitted and found proved, as amended 2. On 22 April 2013 the results of Patient A s Echocardiogram electrocardiogram ( ECG ) were received by the Surgery and you failed to: a. review the ECG results until 29 May 2013; Admitted and found proved, as amended b. act upon the abnormal ECG results until 29 May 2013; Admitted and found proved, as amended c. arrange for urgent referral to Paediatric Cardiology or a paediatrician; Found not proved, as amended d. arrange for review or follow up of Patient A. Admitted and found proved, as amended 3. On 23 April 2013 the results of Patient A s blood test results were received by the Surgery and you failed to: a. review the blood test results until 29 May 2013; Admitted and found proved b. reach an appropriate diagnosis; Found proved c. act upon the abnormal blood test result; Found proved 3

4 d. arrange for review or follow up of Patient A. Found proved 4. On 29 May 2013, Patient A s mother spoke to you on the telephone and told you that Patient A was experiencing shortness of breath when walking to school, or words to that effect, and you failed to: a. Make a contemporaneous record of this telephone conversation; Withdrawn by the GMC b. a. arrange for any follow up or review of Patient A; Admitted and Found proved, as amended c. b. discuss the abnormal blood test result with Patient A s mother; Found not proved, as amended d. c. implement any treatment in light of Patient A s abnormal blood test result. Found proved, as amended 5. On 12 June 2013, you added to the entry made of the consultation with Patient A on 22 April 2013, the following: a. Obs/Problem: bit out of breath occasional ; Admitted and found proved, as amended b. if worse shortness of breath; unwell go to a/e. Admitted and found proved 6. On 14 June 2013, you added the words Abnormal Contact Patient to Patient A s medical records with regard to the blood test results received on 23 April Admitted and found proved 7. On 18 July 2013, you added the words telephone encounter to Patient A s medical records in respect of the telephone call with her mother on 29 May Admitted and found proved 8. You failed to clearly indicate that your actions as outlined at paragraphs 5 to 7 were retrospective changes to Patient A s medical records. Admitted and found proved 9. The effect of your actions as outlined at paragraph 5(a) were such as to give an impression that you had taken a thorough history with regard to Patient A s symptom of breathlessness. Found not proved 10. The effect of your actions as outlined at paragraph 5(b) were such as to give an impression that you had given Patient A advice to attend at an accident and 4

5 emergency department in the event that her symptoms deteriorated. Withdrawn by the GMC The effect of your actions as outlined at paragraph 6 were such as to give an impression that you had reviewed and actioned Patient A s abnormal blood test result on or around 23 April Found proved Your actions as outlined at paragraphs 5 to were: a. misleading; Found proved, as amended, in respect of paragraphs 8 and 10 only b. dishonest. Found not proved, as amended And that by reason of the matters set out above your fitness to practise is impaired because of your misconduct. Attendance of Press / Public The hearing was all heard in public. Determination on Facts - 08/11/2016 Dr Kazi: Amendments to the Allegation 1. Throughout the course of the hearing, several applications were made to amend the Allegation. No objection was made to these applications and the tribunal acceded to these applications as it was satisfied that no injustice would be caused. The amended Allegation is set out in the body of the determination below. Withdrawal of paragraphs of the Allegation 2. Prior to this hearing, Dr A, the expert witness for the GMC and Dr B, your expert witness, met to prepare an agreed report. The tribunal has had sight of the agreed report, dated 5 and 6 September In the light of the agreed findings set out in this report, Ms Johnson applied to withdraw the following paragraphs (as originally numbered): Paragraphs 1(a)(iv); 1(a)(v)(2); 1(a)(v)(3); 1(a)(v)(4); 1(c)(i); 1(c)(ii); 1(c)(iv); 1(c)(v); 4(a); and 10. The tribunal acceded to this application and announced those paragraphs as withdrawn. 5

6 Admissions 3. On your behalf, Ms Davis made the following admissions: Legal advice Paragraphs 1(e); 2(a); 2(b); 2(d); 3(a); 4(a); 5(a); 5(b); 6; 7; and The tribunal accepted the advice of the Legal Assessor who advised that the burden of proof rests with the GMC and the standard of proof is the civil standard, namely the balance of probabilities. 5. In relation to those paragraphs which allege a failure, the Legal Assessor advised that, in order to find the paragraph proved, the tribunal must be satisfied that you were under a duty to act in the way alleged. If the tribunal concludes that you were under no such duty there can be no failure and it must find the paragraph not proved. Only if the tribunal finds that you were under a duty, must it determine whether you, failed to act as alleged. 6. In respect of dishonesty, the Legal Assessor advised that the GMC must satisfy the tribunal, on the balance of probabilities, that the registrant (you) were acting dishonestly. He advised that the test for dishonesty is set out in the case of Twinsectra Ltd v Yardley and others [2002] UKHL 12, 2 AC 164 in which Hutton LJ stated: "before there can be a finding of dishonesty it must be established that the registrant's conduct was dishonest by the ordinary standards of reasonable and honest doctors and that she herself realised that by those standards her conduct was dishonest. [the registrant] should not escape a finding of dishonesty because he sets his own standards of honesty and does not regard as dishonest what he knows would offend the normally accepted standards of honest conduct." 7. With the agreement of both Counsel, the Legal Assessor clarified whether the test applied should be reasonable and honest doctors or reasonable and honest people by reference to the case of Dowson v GMC [ ] EWHC 3379 (Admin) in which Edis J summarised the approach as: Evidence the relevant standard is the same whether it is derived from the standards of reasonable and honest doctors or reasonable and honest people. What is necessary is to attribute to which ever notional group is the theoretical arbiter enough knowledge of the context and purpose of the activity involved to allow an informed judgment to be developed. 6

7 8. In addition to the written evidence before it, the tribunal has also heard oral evidence from the following witnesses: Ms B note-taker at the NHS England meeting on 12 December 2013 Dr C Associate Medical Director of NHS England at the relevant time Ms A Practice Manager at Westbourne Green Surgery (the Surgery) at the relevant time Dr D locum GP at the Surgery at the relevant time Dr A GMC expert witness Dr E GP and Medical Director of the Practitioner Health Programme Dr B Your expert witness 9. You also gave oral evidence to the tribunal. The tribunal has taken account of all of the evidence, both written and oral, in making its findings of fact. Submissions 10. The tribunal has taken account of the written and oral submissions of both counsel when making its findings of fact. These are a matter of record and the tribunal has not therefore rehearsed them in detail in this determination. Tribunal findings 11. In its consideration of each outstanding paragraph of the Allegation, the tribunal has been referred to a number of sources of evidence. However, it bore in mind that you are the main source of evidence relating to the consultation with Patient A, the telephone consultation with Patient A s mother, your subsequent alteration of Patient A s notes and your filing of Patient A s blood results. 12. The tribunal noted that there are aspects of your evidence about your consultation with Patient A and subsequent telephone consultation with Patient A s mother which have apparently become clearer in your mind over time. Accordingly it approached those parts of your evidence with caution. Nevertheless, it accepted that you have continued to think through these events since the death of Patient A, going over what you did and what you could have done. It also accepted that there is a difference between, for example, giving evidence under pressure and in distressing circumstances to the Coroner, and sitting down in a calm environment to formulate a detailed witness statement and that the latter could have assisted you to achieve a more complete recollection. The tribunal found your oral evidence credible. It found 7

8 that you were honest in your concession, during your oral evidence, that you found it difficult to identify your true recollection now as you have gone over the events in your own mind so many times. 13. Finally, the tribunal reminded itself that, in making its findings of fact, it must have regard to all the evidence and decide whether an event is more likely than not to have occurred and not whether you have a full and detailed recollection of events. Background 14. You completed your pre-clinical medical training in You held various hospital-based training posts and started work in General Practice in You worked as a salaried GP since 2004 and, since December 2004, you worked as a salaried GP in the Westbourne Green Surgery where you were employed by Dr F who was the sole principal. 15. Both you and the practice manager, Ms A, gave evidence that the practice presented particular challenges to the doctors working in it. The bulk of the patients suffered significant social deprivation, often associated with poor housing, which impacted upon their health. Many spoke little English. Doctors were required to write numerous letters on behalf of patients and often conduct consultations with the assistance of an interpreter. 16. In December 2012 the practice started to computerise its record keeping. Ms A described the Docman system which was in place at the time of your consultation with Patient A as inefficient and cumbersome. The record keeping system was changed on more than one occasion. 17. The tribunal heard that Patient A was a 15 year old girl complaining of palpitations and breathlessness, who had attended a consultation on 22 April 2013 with her mother. You were speaking to Patient A in English, but were communicating at the same time with her mother in Bengali. The tribunal heard that Patient A s mother was anxious and that you were attempting to allay her concerns as well as speak to Patient A. Patient A s mother had consulted you on several prior occasions because of other family difficulties, which included the ongoing treatment of her son following a serious road traffic accident. You had also completed other documentation for him including letters to his university and social security forms. Patient A had been seen on 12 April 2013 at the surgery by Mr A who had diagnosed and treated her for a chest infection. 18. Having considered all of the evidence, both written and oral, the tribunal concluded that the consultation with Patient A and her mother on 22 April 2013 was a particularly difficult one given that you were communicating in two languages at once and attempting to speak to a patient while reassuring her anxious mother whose background family difficulties were well known to you. 8

9 19. The tribunal heard that you considered it probable that Patient A s palpitations were as a result of the stress she was under at the time, both family and schoolrelated, and that the earlier chest infection may have accounted for her reported occasional breathlessness. Nevertheless, you ordered blood tests and an electrocardiogram (ECG) in case her symptoms were caused by an underlying heart condition. You instructed Patient A s mother to bring the results of the ECG back to the Surgery and deliver them directly to you in your room. 20. Following the consultation, Patient A returned her ECG results to reception. The blood test results were also received and logged on the Surgery s computer system. For reasons that were explored in evidence, relating to both difficulties with the computerised system and the backlog of work that you had built up, you did not view these results until 29 May 2013 when Patient A s mother telephoned you regarding Patient A s ongoing breathlessness. You accessed her results and immediately referred Patient A to community cardiology. 21. On 12 June 2013, you were telephoned by the Coroner who informed you that Patient A had died. The cause of death was subsequently recorded by the Coroner as 1a acute heart failure and b. aneurysm of the aortic sinus and ruptured cusp of aortic valve. 22. On 12 June 2013 following receipt of this information, you made two additions to your previous notes of the 22 April and 29 May However, you did not mark on the notes that these were later additions. 23. The tribunal noted the evidence of Dr G, a paediatric cardiologist, to the inquest that I would agree even as a cardiologist that anxiety issues are more likely to be the reason for [Patient A s symptoms]. 24. The GMC do not allege that any of your actions or omissions contributed to Patient A s death. Findings 25. The tribunal has made the following findings of fact: Paragraph 1(a)(i) found proved 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: a. take an adequate medical history in that you did not enquire as to: i. any exacerbating and/or relieving factors; 9

10 26. The tribunal heard that this paragraph of the Allegation relates to your alleged failure to ask what brought on Patient A s symptoms, what alleviated them, and how long those symptoms lasted. 27. In your witness statement you said that you asked Patient A whether her palpitations were affecting her daily activities. She responded that she was stressed because of her GCSEs and her brother s road traffic accident, but she was still attending school and was managing to sleep. 28. You told the tribunal that you could see that Patient A was sat calmly and quietly in the consultation. You said that you knew Patient A and her family well. This meant that you knew certain details such as the fact that the family had no car and so you assumed that Patient A walked to school, which was near to her home and the Surgery. She did not report any difficulties with this. You also knew that Patient A s family had undergone significant family difficulties recently, that her mother was very anxious, and that Patient A was about to take her GCSEs. 29. You denied this paragraph of the Allegation as you stated that, given the above factors, the history taken by you was adequate to diagnose that stress was probably the cause of Patient A s fast heart rate, but that there could possibly be an underlying cardiac cause which is why you referred her for further investigation. 30. The tribunal accepted the opinion of Dr A and Dr B, as set out in their joint report of 5 and 6 September This states: We agree that Dr Kazi should have recorded specific information about exacerbating and relieving factors for [palpitations and breathlessness] particularly the relationship to anxiety and relationship to exercise. They also stated: Had the additional information described in Dr Kazi s witness statement also been recorded, there would still have been significant omissions. However, they drew different conclusions as to the overall adequacy of the history taking. 31. The tribunal heard the evidence of Dr A that the history taken was inadequate because it did not include sufficient enquiries to establish what brought on the palpitations and what caused them to stop. His opinion was that, if Patient A had revealed that exertion brought on the palpitations and rest alleviated them, that would have been powerful evidence that they were not caused by stress. The answer was also capable of providing a useful background against which to assess the ECG and blood test results in due course. 10

11 32. Dr B s opinion was that, although you should have asked the question at some stage, your failure to do so did not make the history taking inadequate because the answer would not have affected your management which was correct in the circumstances, namely to arrange for Patient A to have an ECG and blood tests. 33. The tribunal preferred Dr A s opinion on this point because it did not accept that the only test of a history is whether it affected the patient s immediate management. The history taken was inadequate because it did not elicit important information, capable of affecting diagnosis including but not limited to the subsequent interpretation of results. Paragraph 1(a)(ii) found proved 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: to: a. take an adequate medical history in that you did not enquire as ii. the duration and periodicity of Patient A s symptoms; 34. It is your case that you asked Patient A whether her fast heart rate was affecting her daily activities and whether it was disturbing her sleep. You said that Patient A told you that she was stressed about her impending GCSE examinations, but was still attending school and was able to sleep. 35. Dr A gave evidence that the history taken was inadequate. He gave this view because it did not include sufficient enquiries to establish the frequency and duration of individual attacks. He also considered that this information was capable of providing a useful background against which to assess the ECG and blood test results in due course. 36. In Dr B s report he states: I would agree that there is no detail of the duration of individual bouts of palpitations, although it is recorded that they had been occurring for a period of two weeks, throughout the day and night i.e. a two-week duration. 37. In the joint expert report, Dr A and Dr B agreed that a two week duration is recorded, but that there is no information about episodes or attacks of palpitations or breathlessness. The report states that Dr A gave evidence that this lack of information demonstrates that the history taking is inadequate because a more serious diagnosis could not be dismissed at this stage. However, Dr B gave evidence that, although the questions should have been asked, the lack of this information did not alter the initial management. It was Dr B s view that if the history demonstrated 11

12 discrete attacks of rapid palpitations and the resting ECG had been normal, then it would have been important to know about duration and periodicity in order to determine whether a 24 hour or event ECG was subsequently required. 38. As with paragraph 1(a)(i), the tribunal preferred Dr A s opinion on this point because it did not accept that the only test of a history is whether it affected the patient s immediate management. This information was relevant and would potentially inform the actions taken on receipt of the ECG. The history taken was inadequate because it did not elicit important information, capable of affecting future treatment including, but not limited to, the subsequent interpretation of results. Paragraph 1(a)(iii) found proved 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: to: a. take an adequate medical history in that you did not enquire as iii. any associated wheeze or sputum; 39. You told the tribunal that Patient A did not present with either wheeze or sputum. However, you acknowledged that you could not remember whether you had specifically asked her about these during the consultation. It is your case that you had Patient A s medical records on screen during the consultation and so were aware that she had had a recent chest infection. In your witness statement you say that you thought Patient A s breathlessness was likely attributable to this recent chest infection. 40. In his report, Dr A states that you should have taken an adequate and appropriate history which would have included features such as He then goes on to list the sort of factors he would expect to see, including any associated wheeze or sputum. 41. In his report, Dr B sets out extracts from the Oxford Handbook of General Practice (2 nd edition, 2005) as to enquiries to be made where palpitations are reported. Wheeze or sputum are not listed as relevant. Dr B gave the view that it would be good practice to ask about wheeze or sputum, but was not essential. 42. The tribunal bore in mind that Patient A s presenting complaint was palpitations. However, Patient A had been treated 10 days previously for a chest infection. Dr A gave evidence that wheeze and sputum were important factors that should have been asked about because of the previous respiratory infection. This would have enabled you to ascertain whether Patient A s breathlessness was linked to her earlier respiratory infection. 12

13 43. The tribunal accepted your evidence that Patient A was sitting quietly at the consultation and did not appear to be experiencing any breathlessness at that time. Neither Patient A nor her mother mentioned any wheeze or sputum to you. However, Patient A reported palpitations but was not experiencing them at the consultation. As the doctor, the tribunal considered that you had a duty to elicit relevant information from your patient. It is not for the patient to determine what is and is not relevant to any potential diagnosis/management plan. 44. Again, the tribunal preferred the opinion of Dr A that this information would have allowed you better to rule out other potential causes of Patient A s symptoms. 45. The tribunal preferred Dr A s opinion on this point as it accepted his view that, at the time in of the examination, it was important to establish whether there was any link between Patient A s reported breathlessness and her earlier respiratory infection. This information was potentially capable of affecting diagnosis. In your witness statement you noted her earlier respiratory infection and said, I thought this might have explained her occasional breathlessness. However, you did not seek further information in relation to this. The tribunal therefore concluded that your history taking was inadequate. Paragraph 1(a)(iv), as originally numbered withdrawn by the GMC 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: to: a. take an adequate medical history in that you did not enquire as iv. the suddenness of onset of Patient A s symptoms; Paragraph 1(a)(iv)(1), as amended found proved 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: to: a. take an adequate medical history in that you did not enquire as v. iv. any relevant lifestyle factors including: 1. caffeine intake; 13

14 46. You admit that you did not ask Patient A about her caffeine intake. However, you deny that your failure to do so meant that your history taking was inadequate. 47. In the joint expert report, Dr A and Dr B agreed that it would have been good practice to ask about caffeine intake. Both experts also agreed that caffeine was a possible cause of Patient A s palpitations. 48. The tribunal accepted the view of both experts that it would have been good practice to ask about caffeine intake. This would have assisted you in ascertaining possible causes of Patient A s palpitations and so was highly relevant to the consultation. The tribunal concluded that your failure to enquire about a relevant contributory factor to Patient A s palpitations was a factor in its finding that your history taking was inadequate. Paragraph 1(a)(v)(2), (3), and (4), as originally numbered withdrawn by the GMC 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: to: a. take an adequate medical history in that you did not enquire as v. any relevant lifestyle factors including: 2. smoking; 3. alcohol intake; 4. stress; Paragraph 1(a)(v), as amended found proved 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: to: a. take an adequate medical history in that you did not enquire as vi. v. any relevant family history; 49. You told the tribunal that you knew Patient A s family history well as you had seen various members of her family on a regular basis, particularly in view of the recent events involving Patient A s brother and Patient A s mother specifically requesting to see you as a result of your language skills. 14

15 50. You told the tribunal that there had been a very unpleasant break up between Patient A s mother and father and so you did not feel that it was possible to ask about that aspect of her family history. 51. In the joint expert report, Dr A and Dr B agreed that it would have been good practice to ask for a family history in a patient complaining of patient palpitations because of the possibility of inherited heart problems. 52. In his expert report, Dr B sets out extracts from the Oxford Handbook of General Practice (2 nd edition, 2005) as to enquiries to be made where palpitations are reported. Under the heading Red flag symptoms it states family history of syncope, arrhythmia, or sudden death. 53. Whilst the tribunal accepted that you had knowledge of Patient A s immediate maternal family history, it concluded that you still had a duty to ask about the red flag symptoms as set out in the Oxford Handbook. This was particularly important given the red flag status attributed to this area in the Oxford Handbook, cited in your own expert s report and in view of the fact that, by your own account, you did not have knowledge of her paternal family history. 54. Taking account of the red flag status of this aspect of history taking and your acknowledgement that you did not ask about this, nor did you have full knowledge of Patient A s family history, the tribunal concluded that your history taking was inadequate. Paragraph 1(b), as amended found proved 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: b. record that you had provide advice to advised Patient A to attend at an accident and emergency department in the event that her symptoms deteriorated; 55. It is your evidence that you advised Patient A to attend Accident & Emergency if her symptoms deteriorated and the tribunal found your evidence on this credible. You admitted that you failed to record this information, but you did not accept that failing to do so was inadequate. However, you also told the tribunal that you do now record such safety netting information. 56. The tribunal accepted the view given by Dr A in his oral evidence that the key thing was for this advice to be given to the patient. One of the witnesses at the inquest, Dr H, confirmed in his evidence that Patient A s mother told him that you 15

16 had advised her daughter to attend Accident & Emergency in the event of any deterioration. 57. The tribunal was satisfied that you had addressed the most important aspect of safety netting ; the provision of appropriate advice to the patient. 58. Dr A acknowledged in his oral evidence that recording that safety netting advice had been given was of more benefit to you than the patient, so that you were able to demonstrate that you had done so. Nevertheless, the tribunal bore in mind the guidance set out in Good medical practice (2013) at paragraph 21: Clinical records should include: b. the decisions made and actions agreed, and who is making the decisions and agreeing the actions c. the information given to patients 59. Good medical practice sets out the duties of a doctor registered with the General Medical Council. In this instance, you did not meet those duties. The tribunal was therefore satisfied that you had a duty to record this advice and you failed to do so. Paragraphs 1(c)(i) and (ii), as originally numbered withdrawn by the GMC 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: c. carry out an adequate examination in that you did not: i. measure the respiratory rate; ii. measure the venous pressure; Paragraph 1(c)(i), as amended - found proved 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: c. carry out an adequate examination in that you did not: 16

17 iii. i. listen to the complete heart; 60. You acknowledge that you did not listen to the complete heart. However, you deny that your examination was inadequate because you say that it was sufficient to enable you to conclude that, although stress was a likely cause of Patient A s symptoms, it was possible that there were other causes and further investigation was needed. 61. The contemporaneous note records only the pulse and blood pressure. However, the tribunal accepted your evidence that you listened to the apex heart and anterior chest. 62. In the joint expert report, Dr A and Dr B agreed that a complete heart examination should have been done. The experts agreed that the four heart valves should have been listened to whilst examining the anterior chest. 63. In his oral evidence, Dr B changed his view as he said that he had forgotten that you had also listened to the anterior chest. He said that he considered this to be sufficient as this would have included a complete heart examination as the other heart valves would be listened to at the same time. The tribunal did not find this evidence convincing because in the agreed experts report Dr B stated, The four heart valves should have been listened to whilst examining the anterior chest. 64. In your evidence to the Coroner, you denied listening to any zones other than the apex, as at that time, I wasn t considering a heart condition. You went on to say that you listened to the chest for any signs of infection. You did not mention listening for heart sounds during your anterior chest examination, as suggested by Dr B. You also denied listening to all four areas of the heart in your oral evidence to this tribunal. 65. In all the circumstances, the tribunal concluded that you should have listened to the complete heart, or should have listened specifically for other relevant signs such as a murmur, whilst conducting the anterior chest examination. In the light of the evidence referred to above, the tribunal concluded that your examination did not include the complete heart. Paragraph 1(c)(ii), as amended - found not proved 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: c. carry out an adequate examination in that you did not: iv. ii. listen to the and lungs; 17

18 66. It has always been your case that you listened to Patient A s lungs. The tribunal has had regard to the evidence you gave to the Coroner where you stated: I listened to the anterior chest for any signs of infections and the bronchus area leaning down and listened. 67. The Coroner questioned you further and you confirm that you listened to the anterior at the front and leaning forward. 68. Your evidence on this point has always been consistent and the tribunal found your oral evidence to it on this paragraph credible. It considered it more likely than not that you did listen to the lungs. 69. The tribunal has taken account of the agreed opinion of the experts, as set out in their joint report that, listening to the heart and lungs would have been acceptable. Although they go on to qualify the nature of an acceptable heart examination, no such qualification is given of a lung examination. 70. In view of the credible evidence before it that you did examine Patient A s lungs, the tribunal found this paragraph not proved. Paragraphs 1(c)(iv) and (v), as originally numbered withdrawn by the GMC 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: c. carry out an adequate examination in that you did not: iv. carry out a peak flow exercise reading; v. assess the level of oxygenation; Paragraphs 1(c)(iii), as amended found not proved 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: c. carry out an adequate examination in that you did not: vi. iii. observe the calves for evidence of deep vein thrombosis; 71. You admit that you did not examine Patient A s calves for evidence of deep vein thrombosis (DVT). However, you state that you had considered the risk factors 18

19 and concluded that such an examination was not necessary. You explained that DVT is extremely rare in children, Patient A had no history of DVT, was not on the contraceptive pill, had no difficulty in walking and had not recently been on holiday. 72. In the joint expert report, Dr A and Dr B agreed that if you had considered the possibility of pulmonary embolism and asked Patient A about any swelling in her calves and received a negative answer, then it was acceptable not to examine her calves. 73. In his report Dr A only states that the examination should involve possibly looking at the calves. 74. In his oral evidence, Dr B stated that DVT was an extremely unlikely diagnosis for Patient A. He gave the view that many reasonable GPs would not examine a patient s calves in these circumstances. 75. The tribunal found your evidence credible that you had considered appropriate risk factors for DVT. Furthermore, in view of the expert evidence, it found that the GMC had not made out that you had a duty to examine Patient A s calves. In these circumstances it found this paragraph not proved. Adequacy of history taking and examination 76. The tribunal has borne in mind that it has not been called upon to rule on the adequacy of the consultation as a whole but 2 aspects of it, namely history taking and examination. For the reasons set out above the tribunal has found those aspect of your consultation to have been inadequate. Paragraphs 1(d)(i), (ii) and (iii) found not proved 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: d. exclude a diagnosis of: i. heart failure; ii. iii. Pneumothorax; Pulmonary embolism; 77. You denied these paragraphs as you contended that you clearly did consider the possibility of a heart condition as you ordered an ECG, and that there was nothing in Patient A s presentation to suggest that she may be suffering from pneumothorax or pulmonary embolism. Furthermore, you said that a CT scan or 19

20 chest x-ray would be required to confirm the presence of either. It would not have been possible for you to exclude these diagnoses in primary care. 78. In the joint expert report, Dr A and Dr B agreed that you should have considered other causes of palpations and being out of breath and those other causes would include these diagnoses. However, they further stated that, from the information recorded in the medical records we both agree that she was not in a position to exclude these diagnoses. In considering this paragraph of the Allegation the tribunal did not rely solely on your record of what you did but also took account of the other evidence of Patient A s presentation at the consultation and the examinations you undertook. 79. In his report, Dr B set out the likely presenting symptoms which would indicate further investigation for these conditions. 80. In his oral evidence, Dr A gave examples as to how you could have done more to examine for these conditions and more comfortably dismiss them. However, the tribunal has taken account of the GMC s withdrawal of the paragraphs of the Allegation that list the possible tests you could have undertaken in order to exclude these conditions (paragraphs 1(c)(i), (ii), (iv) and (v) as originally numbered). 81. In his oral evidence, Dr B stated that it would not be possible to exclude any of these diagnoses without specialist investigation. He told the tribunal that the point of primary care is to dismiss other possible causes as unlikely and focus on investigating the most likely diagnoses. 82. The tribunal accepted that it would not be possible for a GP to exclude any of these conditions. This would only be possible with specialist investigation. However, it considered you did have a duty to consider their likelihood. 83. The tribunal has already found that you had considered and dismissed as unlikely appropriate risk factors for DVT. It found your evidence credible that Patient A did not present with any symptoms that indicated that these conditions were a likely cause of her palpitations and breathlessness, as detailed in the expert evidence. 84. Having accepted your evidence that Patient A did not present with any symptoms that would have indicated further investigations for these conditions, the tribunal was not satisfied that, in the circumstances of this case, you had a duty to investigate further. In any event, the tribunal accepted that it is not the role of primary care to exclude such serious conditions, it can only consider the likelihood and order further investigations accordingly. Paragraph 1(e), as amended admitted and found proved 20

21 1. On 22 April 2013 Patient A (a minor) and her mother attended a consultation with you at Westbourne Green Surgery (the Surgery ) during which you failed to: e. maintain an adequate record of the consultation in that you did not record the information as outlined at paragraph 1(a), c and to (d). Paragraphs 2(a) and (b), as amended admitted and found proved 2. On 22 April 2013 the results of Patient A s Echocardiogram electrocardiogram ( ECG ) were received by the Surgery and you failed to: a. review the ECG results until 29 May 2013; b. act upon the abnormal ECG results until 29 May 2013; Paragraph 2(c), as amended found not proved 2. On 22 April 2013 the results of Patient A s Echocardiogram electrocardiogram ( ECG ) were received by the Surgery and you failed to: c. arrange for urgent referral to Paediatric Cardiology or a paediatrician; 85. You denied that you had a duty to make an urgent referral to paediatric cardiology or a paediatrician in April 2013 as this was the first time Patient A had complained of a fast heart rate, she appeared otherwise well and there were a number of external factors that were likely to be creating stress in her life, which was your working diagnosis. You accept however that, if you had reviewed the ECG in a timely fashion you would most likely have asked Patient A to return for a review in one week and, if her symptoms persisted, would have made a non-urgent referral to cardiology. 86. In the joint expert report, Dr A and Dr B agreed that, if you had obtained a history and examination strongly suggestive of cardiac abnormality and viewed the ECG, then an urgent referral was indicated. Nevertheless, both experts agreed in their oral evidence that stress was the most likely diagnosis for Patient A s symptoms. 87. Dr A told the tribunal that, had Patient A told you that her palpitations were exacerbated by exercise, this would have warranted an urgent referral. The tribunal has found that you had a duty to ask Patient A about exacerbating factors but failed to do so. In his report, Dr A gave the view that the ECG abnormalities were so pronounced that an urgent referral was required in April

22 88. In his report, Dr B gave evidence that, although the ECG was abnormal, a non-specialist GP would not have been too concerned about the abnormalities and would have been reassured that the rhythm was confirmed as sinus tachycardia (i.e. no irregular heartbeats or abnormal electrical impulses but an increased rate of normal heartbeats). 89. The tribunal had regard to the transcripts of the inquest hearing and the coroner s decision. At the inquest, Dr I, a consultant paediatric cardiologist, gave expert evidence. He gave the view that the ECG indicated that a cardiological opinion was required, but not necessarily an urgent one. 90. A second expert, Dr G, a consultant paediatric cardiologist, also gave evidence at the inquest that, had he seen Patient A, he would have thought that her symptoms were most likely anxiety related. 91. The tribunal concluded that, while it is clear that you should have reviewed the ECG in a timely fashion and that, as a result of this, would likely have made a referral to a cardiologist, it is not satisfied that you had a duty to make an urgent referral. The experts agreed that stress was the most likely cause of Patient A s symptoms given her age, presentation, the ECG results and the fact that she remained clinically stable until her death. Although Dr A gave evidence that an urgent referral would be required if exertion exacerbated Patient A s symptoms, this view is not supported by the other experts, particularly the cardiology specialists, who have given opinions in relation to your management of Patient A. 92. In all the circumstances, the tribunal concluded that although you had a duty to make a referral on 22 April 2013 to Paediatric Cardiology or a paediatrician, the evidence did not support the allegation that you had a duty to make an urgent referral at that time. Paragraph 2(d), as amended admitted and found proved 2. On 22 April 2013 the results of Patient A s Echocardiogram electrocardiogram ( ECG ) were received by the Surgery and you failed to: d. arrange for review or follow up of Patient A. Paragraph 3(a) admitted and found proved 3. On 23 April 2013 the results of Patient A s blood test results were received by the Surgery and you failed to: a. review the blood test results until 29 May 2013; 22

23 Paragraph 3(b) found proved 3. On 23 April 2013 the results of Patient A s blood test results were received by the Surgery and you failed to: b. reach an appropriate diagnosis; 93. You have denied this paragraph as you say that it is not clear what is alleged by the GMC as an appropriate diagnosis. If this paragraph relates to Patient A s vitamin D deficiency, then you admit it. However, if this paragraph relates reaching an appropriate diagnosis in relation to Patient A s palpitations and breathlessness, then it is denied. 94. The tribunal took account of Ms Johnson s submissions on the facts and concluded that paragraph 3 relates to Patient A s vitamin D deficiency and your alleged failure to address this. Given your admission that you did not diagnose vitamin D deficiency, the tribunal has found this paragraph proved. Paragraphs 3(c) and (d) found proved 3. On 23 April 2013 the results of Patient A s blood test results were received by the Surgery and you failed to: c. act upon the abnormal blood test result; d. arrange for review or follow up of Patient A. 95. You accept that you did not act on the abnormal blood test results or arrange for review or follow up of Patient A. However, you do not accept that you had a duty to do so on 23 April 2013, had you reviewed the results at that time. You said that, at that time, it was necessary to investigate the cause of Patient A s palpitations and breathlessness. It is your case that Patient A had a history of vitamin D deficiency and there was no danger in delaying dealing with this which would only involve providing advice to get more sunlight and take a vitamin D supplement. 96. In the joint expert report, Dr A and Dr B agreed that you should have arranged a follow up and that failure to do this was seriously below the standard of care expected of a reasonably competent GP. 97. The tribunal accepted that the cause of Patient A s palpitations and breathlessness was the more pressing concern and that her vitamin D deficiency had no bearing on this. However, it considered that you still had a duty to act upon the abnormal blood test result, provide Patient A with advice regarding sunlight and supplements and, as agreed by the experts, arrange for review or follow up. There is 23

24 no evidence that you did so, even after a delay of some six weeks, when you spoke to Patient A s mother on the telephone on 29 May In her submissions on the facts Ms Davis said there was no downside to delaying dealing with the low vitamin D. The tribunal considered that this submission would have been more persuasive were there evidence that you had planned in a review of Patient A at a later date. Having failed to review Patient A s ECG and blood test results for some six weeks, there is no evidence to suggest that you had given any consideration to treating or reviewing Patient A s vitamin D deficiency. Paragraph 4(a), as originally numbered withdrawn by the GMC 4. On 29 May 2013, Patient A s mother spoke to you on the telephone and told you that Patient A was experiencing shortness of breath when walking to school, or words to that effect, and you failed to: a. Make a contemporaneous record of this telephone conversation; Paragraph 4(a), as amended admitted and found proved 4. On 29 May 2013, Patient A s mother spoke to you on the telephone and told you that Patient A was experiencing shortness of breath when walking to school, or words to that effect, and you failed to: b. a. arrange for any follow up or review of Patient A; Paragraph 4(b), as amended found not proved 4. On 29 May 2013, Patient A s mother spoke to you on the telephone and told you that Patient A was experiencing shortness of breath when walking to school, or words to that effect, and you failed to: c. b. discuss the abnormal blood test result with Patient A s mother; 99. It is your case that that you did discuss the abnormal blood test results with Patient A s mother during this telephone call. In your witness statement you said that you received a message on the EMIS system requesting that you call Patient A s house, or brother s mobile, regarding her results. You said that, during this call, you remember her mother saying something along the lines of oh the vitamin D is low again 100. The tribunal found your oral evidence on this point persuasive. Given that the purpose of the call was to discuss Patient A s test results, the tribunal concluded that it was more likely than not that you would have either have been directly asked about the blood test results by Patient A s mother, or would have raised them 24

25 yourself. Furthermore, the tribunal found your recollection of Patient A s mother s comments about the vitamin D during this call to be credible. Paragraph 4(c), as amended found proved 4. On 29 May 2013, Patient A s mother spoke to you on the telephone and told you that Patient A was experiencing shortness of breath when walking to school, or words to that effect, and you failed to: d. c. implement any treatment in light of Patient A s abnormal blood test result The tribunal has already found that you had a duty to deal with Patient A s vitamin D deficiency and that you failed to do so. This was a further opportunity, some six weeks after the results were received by the Surgery, for you to deal with the matter. Although the tribunal accepted your evidence that you spoke to Patient A s mother about the vitamin D deficiency during this telephone call, you have never asserted that you gave advice about this and the medical notes do not suggest that you implemented any treatment on 29 May You said that you would have dealt with this when you saw Patient A again, but there is no evidence that a review was scheduled for Patient A In view of its earlier finding that you had a duty to deal with Patient A s vitamin D deficiency and that you failed to do so, and the evidence which suggests that you took no action during this telephone call, the tribunal has found this paragraph proved. Paragraph 5(a), as amended, 5(b), 6, 7 and 8 admitted and found proved 5. On 12 June 2013, you added to the entry made of the consultation with Patient A on 22 April 2013, the following: a. Obs/Problem: bit out of breath occasional ; b. if worse shortness of breath; unwell go to a/e. 6. On 14 June 2013, you added the words Abnormal Contact Patient to Patient A s medical records with regard to the blood test results received on 23 April On 18 July 2013, you added the words telephone encounter to Patient A s medical records in respect of the telephone call with her mother on 29 May You failed to clearly indicate that your actions as outlined at paragraphs 5 to 7 were retrospective changes to Patient A s medical records. 25